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Clinical audit

Definition

The systematic review of elements of clinical care against predetermined criteria, with the aim of identifying areas for improvement and then developing, implementing and evaluating strategies intended to achieve that improvement.

Background

Clinical audit is a cyclical process where individuals, teams or services: • identify a clinical topic of interest or concern • identify sources of appropriate data which will assist in assessing the topic, including medical records and feedback from senior doctors, other clinicians and consumers • review the data against set criteria and standards • identify areas for improvement • implement those improvements • assess the impact of those improvements. Audits measure elements of care including structure, processes and potentially outcomes of care. Clinical audit can provide information about the quality of care provided in a narrowly defined clinical area (for example, a single disease state or a single presentation). Clinical audit generally uses clinical level data and when managed by senior doctors has high levels of acceptability and is viewed as a valuable means of informing doctors about their care delivery. By contrast, traditional clinical indicators have less acceptability amongst doctors as their data sources may be non clinical data sets and because the measures chosen may not have local clinical applicability. Professional bodies such as the medical colleges support and encourage their members and fellows to participate in clinical audit. Participation in clinical audit is mandatory as part of a continuing professional development (CPD) program for some specialist colleges. Successful clinical audit requires: • a clearly defined issue or problem • an ability to measure clinically relevant elements of care which clearly reflect that problem • an ability to apply that measure in a rigorous and consistent way which best reflects care • an ability to change care processes to drive any subsequent improvement in the chosen measure • sufficient resources to ensure that the work can be undertaken appropriately and in a manner which ensures clinician engagement and support • clinical leadership. 128 Partnering for performance – Toolkit

The quality of the information obtained by clinical audit is a direct reflection of the design and conduct of the audit. Clinical audit should always be subject to informal peer review to ensure local relevance and to maximise acceptance. Two Cochrane systematic reviews and a meta-analysis have been conducted on the use of audit and feedback on professional practice and outcomes (Jamtvedt et al 2003; Jamtvedt et al 2006). The reviews show that audit has a moderate impact on clinical practice, but the impact of audit is dependent on the level of performance prior to the audit, and on the feedback process. The establishment of valid criteria, the training of reviewers, particularly if they are conducting their own audits, and the provision of effective feedback are important factors in the validity of the method.5 Comparisons between clinical settings are difficult as participants and the interventions themselves vary. Thus clinical audit should be seen as an organisation or service specific activity. In the absence of consistent processes for data management and reporting, considerable caution should be applied in interpreting inter or inter unit comparisons.

Purpose

The purpose of clinical audit is to improve the quality of health care services by systematically reviewing the care provided against set criteria. To do so, there should be a clear understanding of current practice. This requires: • clear and consistent definitions • consistent and reproducible data sources • an ability to change care delivery if improvement is required. The gap between the criteria and the assessed performance provides guidance for prioritising improvement strategies. Clinical audits that are ongoing and allow the monitoring of care over time may become ‘clinical indicators’ (see Clinical indicator tool). Clinical indicators based on ongoing clinical audit using clinical level data are likely to have significant clinical acceptability. Clinical audit may, in certain circumstances, provide guidance around elements of an individual senior doctor’s clinical performance (for example, colonoscopy perforation rates). Clinical audit, if well designed, appropriately managed, resourced and supported by those senior doctors whose care is being audited, provides reasonable clinical level evidence of elements of a senior doctor’s care delivery. Clinical audit will rarely provide evidence of ‘whole of care’. For this reason, care should be taken in interpreting clinical audit information in the performance context. Clinical audit may provide an excellent opportunity to facilitate dialogue with senior doctors and enhance clinical practice.

5 The literature review for Clinical audit is available at www.health.vic.gov.au/clinicalengagement Partnering for performance – Toolkit 129

How to undertake clinical audit

The department is not prescribing a specific approach to clinical audit as there is considerable literature on the successful undertaking of clinical audit. Individual professional colleges often provide craft group specific guidance. The department notes, however, the importance of ensuring sufficient resources to successfully complete the audit cycle and strongly encourages to work with their senior medical staff to design the most appropriate structure and supporting processes in the local context. A useful resource to support the local development of clinical audit is the NHS National Institute for Clinical Excellence Principles for best practice in clinical audit (2002).6 Professional colleges also provide guidelines for undertaking clinical audit.

Critical risks to consider in using the tool

Clinical audit will fail if key barriers are not addressed prior to the commencement of the audit process. Key barriers include: • lack of clarity re purpose of audit (what are we trying to achieve?) – audit must be framed around improving patient care and has no role as an investigational tool • inconsistent approaches to data collection and management • insufficient resources to support the audit process • lack of expertise in audit project design and analysis • lack of planning • lack of medical engagement and leadership • poor professional culture and poor relationships between professional groups and agencies, and within audit teams • absence of trust between senior doctors and managers • lack of integration with other activities (including processes) • an inability of senior doctors to change or improve the care processes being measured. Clinical audit can provide a valuable source of data for reviewing elements of clinical performance. However, this data should not be used as the sole source of information to inform a performance development process for a senior doctor.

Victorian approach

Every senior doctor in Victorian public hospitals should be supported by their organisation to ensure they are involved in auditing elements of their clinical care on at least an annual basis. Ideally clinical audit should be ongoing to assist in the monitoring of care. Senior doctors should be involved in the management of clinical audit, including the design, oversight and subsequent improvement processes.

6 More information is available at http://www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf